Staff perceptions of end-of-life care in long-term care

OBJECTIVE: Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. DESIGN, SETTING, AND PARTICIPANTS: Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents' last month of life. MEASUREMENTS: Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted "need for change" scores were calculated as the product of perceived importance and need for improvement. RESULTS: Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. CONCLUSION: Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.     

Patient‐centred care training needs of health care assistants who provide care for people with dementia

It is well documented that Health care assistants (HCAs) provide the most hands‐on care to residents in aged care facilities, and play a critical role in the provision of care to dementia residents. Over the last 25 years, a philosophy of person‐centred care has become the preferred approach to care and this has meant that HCAs are encouraged to get to know the resident very well. This paper reports the experiences of HCAs in caring for people at end‐of‐life, identifies the skills required for their work and examines the education provided against these skills. Semi‐structured interviews were conducted in 49 facilities (n = 34) across New Zealand and data analysed thematically, with the aim of critically examining the adequacy of education for health care assistants which meets their needs within a person‐centred environment. The results confirm that the skills include traditional tasks of care (showering, feeding, toileting, and dressing) but the increasingly important communication and de‐escalation skills, both verbal and non‐verbal, have become central to their care skills. Education provided has not sufficiently shifted focus to include these more complex skills. Provision of educations that acknowledges the increased complexities of their role needs to be provided. As well, facilities need to be challenged to reconsider the HCA's position in the facility care tem.     

Therapeutic massage: an education program for rural and remote workers in the palliative care field

This paper, drawing upon data from a Rural Health, Support, Education and Training (RHSET) funded project, focuses on the evaluation of a massage education program developed specifically for rural and remote palliative care workers. An 8 week pilot massage education course was run for palliative care workers in the Albury–Wodonga area and, from this course, an instructional video education package on massage has been developed. The program was evaluated by using a questionnaire, journals and focus group interviews. Feedback from participants was incorporated into both the pilot course and final education package, which was consistent with the action research framework. The major findings of the project were that skill development in the therapeutic use of massage was attained and that job satisfaction was indeed achieved by palliative care workers.     

Ethical challenges in the provision of end-of-life care in Norwegian nursing homes

As in other Western countries, most Norwegian nursing home patients are suffering from multi-pathological conditions and a large majority of them will die in the nursing home. End-of-life care represents many challenges, and it is a widespread concern that several nursing homes lack both resources and competence to ensure good quality care. This article examines the types and prevalence of ethical challenges in end-of-life care as nursing home staff consider them, as well as what they believe can help them to better cope with the ethical challenges. It is based on a national survey probing Norwegian nursing homes’ end-of-life care at the ward level conducted in 2007. 664 respondents from 364 nursing homes answered the questionnaire, representing 68% of the patients and 76% of the nursing home sample.     

The nursing home in long-term care education

Nursing homes have long been used to teach geriatric medicine to medical students, primary care residents, and geriatric medicine fellows, but we may be able to more appropriately use this clinical setting by addressing principles of long-term care in addition to general geriatrics. Long-term care education starts with developing an understanding of the health care system and how to use services to maximize the functional abilities of our frailest elderly, and, depending on the needs of specific learners may incorporate skills such as quality improvement methodology, interdisciplinary team participation, managing infection risk within a community, and optimally transitioning patients between care venues. At each level of medical education, specific long-term care learning outcomes should be established with attention given to appropriate assessment of these outcomes. Curricular elements should be directed by the needs of the specific group of learners and the resources of the institution.     

Job satisfaction of nursing assistants in long-term care

A study of job satisfaction of nursing assistants (NAs) was conducted in two nursing homes (one in a relatively poor urban neighborhood, the other in an affluent suburban neighborhood). When it comes to job content, NAs were more satisfied than dissatisfied. However, they are less satisfied with working conditions. The NAs of the suburban facility were less satisfied than those of the urban facility. Managers need to focus more on the work environment than on job content to develop a more satisfied work force.     

Optimizing the role of social workers in advance care planning within an academic hospital: an educational intervention program

Advance Care Planning (ACP) promotes communication to help patients express future health-care preferences and goals for their medical care. Social workers (SWs) are trained to facilitate complex conversations and assist in various ACP tasks across clinical settings. This three-part mixed-method interventional study implemented a comprehensive education and training program for SWs of a large academic hospital, which used pre- and post-training evaluations, chart review, and qualitative data from debrief sessions to examine ACP skills and confidence, and assess the number of ACP conversations initiated with patients. Self-reported level of preparation to facilitate ACP conversations improved significantly (n = 26; pre 36% versus post 82%; p < .05). A 4-month post-intervention chart audit showed an 8.69 fold increase in the number of initiated ACP conversations. Qualitative analysis identified key themes regarding barriers and enablers of initiating ACP conversations during standard care from the perspective of SWs.     

Evaluation of an educational program in health care teams

In July 1975, the Division of Ambulatory and Community Medicine at the University of California, San Francisco, initiated an interdisciplinary team education program as part of a required core medical clerkship in primary care. Significant emphasis was placed on evaluation of student and patient service outcomes. Overall, students rated the teaching in the program as moderately effective. The major measured gain for students was in their formal knowledge of the principles of teamwork, with secondary gains in patient problem-solving skills. The gains in knowledge were greatest for medicine and pharmacy students. During the team education program, the average number of patients seen by student providers was greater than it had been during previous clerkships. Similarly, the comprehensiveness of care provided was higher during the team education program. Although no significant differences were found between student teams and individual providers, those teams with consistent membership from all three participating disciplines (medicine, pharmacy, and nursing) delivered more comprehensive care.     

Evaluation of a Chaplain Residency Program and Its Partnership with an In-Patient Palliative Care Team

In 2009 a Consensus Conference of experts in the field of spiritual care and palliative care recommended the inclusion of Board-certified professional chaplains with at least 1,600 hours of clinical pastoral education as members of palliative care teams. This study evaluates a clinical pastoral education residency program’s effectiveness in preparing persons to provide spiritual care for those with serious illness and in increasing the palliative care team members’ understanding of the chaplain as part of the palliative care team. Results showed chaplain residents felt the program prepared them to provide care for those with serious illness. It also showed that chaplain residents and palliative care team members view spirituality as an integral part of palliative care and see the chaplain as the team member to lead that effort. Suggested program improvements include longer palliative care orientation period, more shadowing with palliative care team members, and improved communication between palliative care and the chaplain residents.     

China: Facing a long-term care challenge on an unprecedented scale

Population ageing is occurring in China at a breathtaking pace and rapidly becoming a major public health issue. Due to the one-child policy, rural/urban migration and other societal changes, the family-dependent long-term care (LTC) of the past will no longer suffice. Barely existent now, both institutional and community-based services will need to expand to meet the growing need. China is still at an earlier stage in economic development and will be challenged to build these services and train staff. Furthermore, many elders are not yet covered by financial and insurance support. This massive demographic transition requires political efforts to develop integrated and sustainable national LTC systems.     

Turnover of certified nursing assistants: a major problem for long-term care facilities

The increasing number of aging Americans who will need long-term care, coupled with the need to keep this care affordable, represents a formidable challenge to the healthcare system. Some response must be made to address what will soon become immediate need. A significant part of the approach to this problem lies in making long-term care as efficient, cost effective, and affordable as possible. Reducing turnover of certified nursing assistants (CNAs) will help achieve these goals. This article discusses the extent, implications, and causes of this turnover and puts forth a program to correct the problem.     

IAGG/IAGG GARN International Survey of End-of-Life Care in Nursing Homes

This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and “end of life,” and a series of questions related to the following areas—attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home.     

Evaluation of an integrated service delivering post diagnostic care and support for people living with dementia and their families

Greater integration of health and social care services is considered vital to ensure sustainable long‐term quality provision for the growing numbers of people living with dementia and their families. Integration of services is at the heart of government policy in England. We evaluated a new integrated service for post diagnostic dementia care, funded as a pilot and delivered through a partnership of statutory and voluntary sector health and social care organisations. The service used an adapted Admiral Nursing service model with a workforce of Admiral Nurses (ANs) and Dementia Advisers (DAs). A mixed method approach was used to assess implementation and outcomes. It involved collection of service activity data, carer reported experience survey data, focus group discussions and interviews with the service delivery team, and the management group. Qualitative data was analysed using a framework approach. About 37.8% of the eligible population registered with the service over the 14‐month pilot period. The self‐referral route accounted for the majority of referrals, and had enabled those not currently receiving specialist dementia care to engage with the service. Carer satisfaction surveys indicated high levels of satisfaction with the service. The caseload management system offered specific benefits. Individual caseloads ensured continuity of care while the integrated structure facilitated seamless transfer between or shared working across AN and DA caseloads. The skill mix facilitated development of the DA role increasing their potential contribution to dementia care. Challenges included managing large workloads and agreeing responsibilities across the skill mix of staff. This model of fully integrated service offers a novel approach to address the problems of fragmented provision by enabling joined‐up working across health and social care.     

Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care

Nursing homes care for people at the end of life (EOL). There is evidence to suggest, however, that nursing staff in these settings is often unprepared to provide a high level of EOL care. This article reports the findings from three preliminary studies that investigated the needs of licensed staff and certified nursing assistants in nursing homes regarding EOL care. The studies involved needs assessment surveys, focus group interviews with staff members, and telephone interviews with nursing home administrators. Data show that the major needs included a lack of knowledge and skills in symptom management; communication difficulties; conflicts with families and physicians; and emotional distress in dealing with time constraints and attachment to residents. Implications for nursing home staff education are described.     

Promoting health and well-being at the end of life through client-centered care

Background: Client-centered care is the cornerstone of the hospice and includes family members and significant others as the client unit. There needs to be a conceptual shift away from “medicalizing” patients at the end of life to promoting their health and considering their well-being a shared responsibility. Using the hospice philosophy of client-centered care can inform and expand health-promotion occupational therapy practice, particularly for people at the end of life. Objectives. This paper examines client-centered care at the end of life as that which enables engagement in meaningful occupation and promotes health and well-being until one dies. Methods: Constant comparison and thematic analysis is used for 12 interviews of hospice professionals. One of the themes, client-centered care, is discussed relative to the promotion of health and well-being at the end of life. Results: Client-centered care is deemed to be an important approach at the end of life. Conclusions/significance: It is determined that client-centered care at the end of life is vital to promote quality of life, health, and well-being. Further research is indicated.